Bioethics Discussion Blog: The “Art” of Making a Diagnosis

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com

IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

FEEDBACK,FEEDBACK,FEEDBACK! WRITE YOUR FEEDBACK ABOUT THIS BLOG, WHAT IS GOOD, POOR AND CONSTRUCTIVE SUGGESTIONS FOR IMPROVEMENT TO THIS FEEDBACK THREAD

Friday, April 06, 2007

The “Art” of Making a Diagnosis

There truly is an art in the mental exercise of a physician making a diagnosis of the patient’s illness. In fact, I think the art really trumps the science itself in most cases. Why do I say that? It is because no two patients are the same and no two same diseases present exactly the same way nor are their courses exactly the same. It is also because lab tests are rarely or ever 100% sensitive and also 100% specific. That means that at times a lab test will miss a disease or will indicate the disease is present but actually it isn’t.

In addition to this variability, is the variability of how thoroughly the physician takes the history from a patient or the variablility of some patients who don’t remember, don’t tell or may understate or embellish their symptoms for one reason or another. Then there is the variability of how the physician performs the physical exam in terms of completeness and attention to discover and interpret pertinent physical abnormalities or lack of abnormalities. Finally, there is the variability in how the physician selects the necessary tests and how the physician interprets the results in terms of supporting or not supporting possible diagnoses. As I have suggested in previous posts, the time available to physician to do all this is also a variable. So, in fact, making a diagnosis is really an art. But it is an art that we try to teach our second year medical students before they step into their clerkship duties in the third year.

Doctors attempt to make a diagnosis through two general methods. There is the experiential “script” in which the physician has learned or by experience has observed the pattern of symptoms and physical finding that lead to a certain disease that was finally diagnosed. When the doctor sees a patient who has virtually the same pattern of symptoms, that disease is immediately brought to mind and is considered high on the list of possible diagnoses. Unfortunately, not all similar patterns represent the same disease. The other method of making the diagnosis is “analytical”. That is, moving through the symptoms and physical findings in a step wise fashion and collecting a list of diagnoses along the way, eliminating some or supporting some by additional history or physical or laboratory findings. This is a slower process than the “script” method but might end up with a more correct diagnosis.

Those who have studied the methods believe that the use of both methods together, in coming to a diagnosis of a patient, is probably the most common and more likely to produce a more rapid and correct result. The pattern of findings suggests a diagnosis that is added to the list of other diagnoses that might be developed by the analytic method and then is subjected, along with the others, to the analytic process of support or elimination.

A complication in making a diagnosis is the issue of whether the symptoms and physical findings and labs all represent a single disease or whether, in fact, the patient actually has two or several symptomatic diseases at the same time. In earlier years, a single symptomatic disease at a time was probably more common. But in the current years, where more people are living into old age when more than one ongoing disease may be present and the older people are taking more medications which have side-effects and drug interactions, the possibility of more than one illness is more likely. We teach our students to start out trying to put all the facts together in terms of one illness but they should be ready to include multiple diagnoses if all the facts don’t seem to apply to one disease and especially if the patient is elderly.

I am presenting this explanation of the diagnostic process to my blog visitors because I think it is important for them to be aware of how their physician might be thinking as their symptoms are being evaluated and what complexities from variabilities physicians face. By knowing a bit about the process, my visitors might be able to understand and judge their physicians’ behavior more realistically and see what has gone on when the doctors makes either the right or wrong diagnoses. ..Maurice.

5 Comments:

At Friday, April 13, 2007 1:25:00 AM, Blogger amanda said...

Have you had an opportunity to look at "How Doctors Think" by Jerome Groopman? He's been debating over at Slate recently. Very interesting examination about decision making in the medical field.

 
At Friday, April 13, 2007 2:07:00 PM, Anonymous stucker said...

I'm going to try putting my email address in this, because I could use some feedback from your readers.

I experienced a benzodiazepine withdrawal syndrome last Sept. I had been on klonipin from Dec 1989 and then reduced to 0 from April thru Sept, 2006.

I really had no idea what was happening to me. It was really bad and sort of indescribable.

I am in an HMO and had primary care doc, nurse presecriber (I have bipolar disorder and PTSD) and a "counselor." They all ignored what happened to me or minimized it. My primary care doc read my requests "I think I had a benzodiazepine withdrawal syndrome, please correct me if I am wrong" and did not answer them (we have EPIC MyChart for email communication).

I ended up with a very nice case manager and a therapist who is not part of the HMO. I will soon go to 0 on valium (I made a cross over from klonipin to valium, after reinstatating to 0.125 klonipin.)

Of course, I know everybody can assign my problems with all this to my psych disabilities. In fact, being off the benzo seems to be helping my anxiety problems. Go figure. I've developed a new appreciation for how good my life is and a sense of deliverance after the withdrawal symptoms stopped.

The case manager and others are saying (but nothing in writing) that I did have a benzo w/d reaction.

I think I'm helplessly embroiled in institutional issues. Plus doctors may be prejudiced against me for several reasons.

What is my point? This benzo thing is a diagnosis. Is it that difficult to make?

Also, The case manager's consultatnt and the Alcohol and drug abuse person I saw (only thing the HMO would pay for) keep referring to Heather Ashton's work as portrayed on benzo.org.uk, which is as an anti psychiatry site. I had seen their stuff before the withdrawal and thought it was extreme and probably not right. Now I am confused by my medical practioners referring to it. I did use it to persuade my nurse prescriber to use Ashton's method of substituting valium for klonipin--based on her work, I've prescribed for myself. Although Prof Ashton (I think she's a pharmacist) has done peer reviewed research, most of what is presented of her work at benzo.org.uk is clinical and highly subjective. Better than nothing, but still iffy. My head is swimming from this irony. Why go thru the HMO at all--why not just use the inernet?!

I plan to get thru this (each decrease causes symptoms for about 5-7 days; then they abate. I may have the drug stored in fat and muscle and have symptoms from that for 1-2? years following withdrawal).

I plan to figure out how to make my HMO report this drug reaction. Then how to get a different primary doc.

Any comments would be welcome. Thank you.

email stucker @ wisc. edu

 
At Friday, April 13, 2007 3:09:00 PM, Blogger Maurice Bernstein, M.D. said...

Stucker, I can see by your posting that you are upset and frustrated with your condition and some of your healthcare providers. I am not sure that your overall concerns are pertinent to this specific thread topic. In addition, I have tried to avoid specific patient diagnosis or treatment commentary on my blog. Nevertheless, I am glad Stucker that you have written this posting here since it shows up clearly one of the problems in making a diagnosis that can lead to errors. It is all about history taking. I read Stucker's entire writings and though I read the words repeatedly "benzodiazepine withdrawal syndrome", the actual symptoms were never specifically described. And this is where diagnostic errors come in. If a hurried physician simply takes the words "benzodiazepine withdrawal syndrome" without going into the details of what the patient actually experienced, the physician might simply set in his or her mind what they have learned from journals, books or their other patients about the symptoms. But this is inadequate history taking since it is essential to know exactly what symptoms the patient experinced, what was the order and durations, if pain, where it was located and what things worsened the symptoms and what did the patient do to attempt to ease the symptoms and whether these attempts were in any way effective. Diagnoses are not made by a diagnosis alone by a patient. Diagnoses are not made alone by a diagnosis made by another physician. Every attempt to make a diagnosis requires a careful and systmatic taking of a history of the symptoms. Diagnoses and treatment approaches are missed because of failure to take a proper and complete history and Stucker what you wrote was incomplete--no symptoms and no detailing of each symptom was described.

Again, I advise you not to write more about this here since, again, I don't want this to become a "diagnostic" blog. I am sure there are many other medical blogs that folks can discuss their symptoms of different diseases and maybe get some cautious general comments from some professionals.

However, I want to make it clear that I clearly understand your frustration about your illness and I thank you for bringing up an example of what I was writing about. I would advise you that you should insist that each physician you visit take the time and attention to go over your history "from scratch". This may permit them to find the best way to treat you. Otherwise, you end up making your own diagnosis and you end up figuring out your own treatment. So far, it doesn't seem like that's working. ..Maurice.

 
At Sunday, August 12, 2012 4:35:00 PM, Blogger Troglodytum Brachiandum said...

Great topic. I find that there is a metaphorical "smell" to a disease process that I did not expect when I entered training.
I had the great joy of diagnosing Landry's Ascending Paralysis (Guillan-Barre Syndrome) in a VA patient in Boston. My attending scoffed, because there were so many other things it could have been - but it "smelled" like GBS, although I have never seen it.
I consider certain specialties to be "left brain" and "right brain." Cardiology is the example of left-brain specialties, and probably pathology and radiology also. They respond to algorithmic throught. Rheumatology, on the other hand, is terribly right-brained and gestaltish.
Thoughts?

 
At Sunday, August 12, 2012 5:01:00 PM, Blogger Maurice Bernstein, M.D. said...

TB and others might be interested in a more recent thread on interpreting the smell of whether a behavior is ethical or not. Here is the link.
..Maurice.

 

Post a Comment

<< Home